DHA Case No. CWK 215379 (Wis. Div. Hearings and Appeals Dec. 12, 2024) (DHS) ↓ Download PDF Under the approved Waiver, DHS does not allow for the use of personal restraints and strictly limits the use of protective equipment. In this case, the petitioner was an 8-year-old autistic child who needed a diaper but exhibited […] Read more

DHA Case No. MPA 215583 (Wis. Div. Hearings and Appeals Dec. 9, 2024) (DHS) ↓ Download PDF Medicaid covers prescriptions drugs that are medically necessary, guided by agency policy on the effective, appropriate, and cost-effective use of the drug. For anti-obesity drugs, specifically Wegovy, agency policy limits coverage to 12 continuous months, after which the […] Read more

DHA Case No. CWA 213491 (Wis. Div. Hearings and Appeals Oct. 24, 2024) (DHS) ↓ Download PDF Home modifications for an IRIS participant must be cost-effective. In this case, the petitioner asked that his tub/shower be replaced with a walk-in shower. The accessibility study concluded this was needed and explained why less expensive options would […] Read more

DHA Case No. CWK 211705 (Wis. Div. Hearings and Appeals Sep. 10, 2024) (DHS) ↓ Download PDF Individual choice of provider is a main tenet of the CLTS program. Even when a county has concerns about a provider, the County Waiver Agency must respect the participant’s choice “unless there is compelling justification not to do […] Read more

DHA Case No. FCP 216075 (Wis. Div. Hearings and Appeals Feb. 24, 2025) (DHS) ↓ Download PDF When an MCO seeks to reduce services, it has the burden of proof and must justify its action. In this case, an Inclusa representative justified its reduction of Supportive Home Care (SHC) hours from 496 to 446 per […] Read more

DHA Case No. FCP 216208 (Wis. Div. Hearings and Appeals Feb. 21, 2025) (DHS) ↓ Download PDF In the Family Care program, the MCO must develop an Individual Service Plan that reasonably and effectively addresses all of the client’s long-term needs—but it must also be cost effective, and it can exclude a service the client […] Read more

DHA Case No. CWA 215956 (Wis. Div. Hearings and Appeals Feb. 28, 2025) (DHS) ↓ Download PDF To be approved as part of an IRIS budget, services must generally be cost-effective. In this case, the petitioner requested a budget amendment to pay $30 and $35 per hour for Supportive Home Care (SHC) services. The agency […] Read more

DHA Case No. CWA 215403 (Wis. Div. Hearings and Appeals Feb. 5, 2025) (DHS) ↓ Download PDF The IRIS program can pay for residential services, such as those provided in an adult family home (AFH), but “residential services” does not include the cost of room and board. In this case, the petitioner asked to increase […] Read more

DHA Case No. CWA 212613 (Wis. Div. Hearings and Appeals May 30, 2024) (DHS) ↓ Download PDF IRIS participants must pay their providers a “usual and customary rate.” In this case, the petitioner’s supported employment provided asked for a rate increase to maintain a competitive wage for employees and pay for rising health insurance, mileage, […] Read more

DHA Case No. CWA 212824 (Wis. Div. Hearings and Appeals Jun. 26, 2024) (DHS) ↓ Download PDF The Department may deny an IRIS budget amendment (BA) request if it is not cost-effective or necessary to achieve the participant’s long-term care outcomes. In this case, the petitioner sought a BA to fund a 4% increase in […] Read more

DHA Case No. CWA 212682 (Wis. Div. Hearings and Appeals Jul. 12, 2024) (DHS) ↓ Download PDF Customized goods or services under the IRIS program must generally be necessary and cost-effective. In this case, the petitioner already had one trained service dog (the training was approved in a prior appeal) but wanted IRIS to pay […] Read more

DHA Case No. CWK 212876 (Wis. Div. Hearings and Appeals Jul. 15, 2024) (DHS) ↓ Download PDF The CLTS program covers home modifications that maximize a participant’s independent functioning in their home. In this case, the petitioner was an autistic child with destructive behaviors. His mother requested durable, solid-wood kitchen cabinetry because he would break […] Read more

DHA Case No. CWK 213060 (Wis. Div. Hearings and Appeals Jul. 15, 2024) (DHS) ↓ Download PDF The parent or caretaker of a CLTS participant may have respite services provided in another’s home if the length of stay is 72 hours or less, even if background checks cannot be completed on all the residents in […] Read more

DHA Case No. 212756 (Wis. Div. Hearings and Appeals Aug. 19, 2024) (DHS) ↓ Download PDF To be approved, IRIS home modifications must address long-term care needs that increase independence; or ensure safe, accessible means of ingress/egress to living quarters; or “otherwise provide safe access to rooms, facilities or equipment within the participant’s living quarters.” […] Read more